Most cases of vertigo arise from conditions affecting the ear, its tissues and its nerves.

Vertigo is a condition with many mimics and many causes, but also with many effective treatments, said Scott L. Kay, MD, FACS. The key to stopping the spinning, the board-certified ear, nose, and throat (ENT) specialist added, is confirming that what a person is experiencing actually is vertigo and then identifying the cause in order to choose the therapy best suited for that patient.

Scott L. Kay, MD, FACS Princeton Otolaryngology Associates

“Many people use the term vertigo to describe other conditions or sensations, such as dizziness, being light-headed, or having poor balance. Those conditions could indicate significant medical issues and should be evaluated, but they are not vertigo, which is the sensation that you are spinning or that everything around you is spinning,” said Dr. Kay, the founder of Princeton Otolaryngology Associates.

He added that the spinning sensation often is accompanied by a sense of being unsteady or off-balance, and can lead to nausea and vomiting. “Vertigo can be very disturbing, disorienting and even debilitating,” said Dr. Kay, who regularly evaluates patients with vertigo at Princeton Otolaryngology’s offices in Monroe and Plainsboro.

“While we have a number of sophisticated tests that we can use to assess people who present with vertigo,  the diagnosis usually can be made at the first office visit by taking a thorough history and performing a physical examination,” Dr. Kay said.

Dr. Kay said that the most common causes of vertigo include:

• Acute labyrinthitis, which is inflammation of the inner ear’s semi-circular canals, a labyrinth of looping tissues and sacs that orient the body to motion and help you maintain your balance;
• Acute vestibular neuronitis, which is inflammation of the vestibular nerve, which also plays an important role in preserving balance;
• Benign positional paroxysmal vertigo (BPPV), which occurs when tiny calcium crystals break away from their normal location in the inner ear and travel to the semi-circular canals; and,
• Meniere’s disease, a disorder of the inner ear.

Other, less-common causes of vertigo include vestibular migraine; vascular compromise; “third window” syndromes, such as superior semicircular canal dehiscence syndrome;  tumors; temporomandibular joint disorders; cervical disorders; anxiety and other emotional/psychiatric conditions; and certain drugs, he said.

‘Vertigo is a very treatable condition. The key is to identify the underlying cause and select the appropriate therapy based on that cause. ’ — Scott L. Kay, MD, FACS

Looking at Duration to Determine Causation

The duration of symptoms is an important factor to consider in identifying the cause of vertigo, Dr. Kay said, noting that he also is interested in what preceded the onset of symptoms and may have triggered them.

“When a person has repeated episodes of vertigo that last for several seconds at a time and that tend to begin when the person changes position, BPPV goes to the top of the list of suspected causes. One of the classic presentations of BPPV involves a brief period of vertigo when a person sits up after having been in bed all night, or even when the person rolls over in bed from one side to the other,” he said.

By contrast, when a person has vertigo that lasts for several hours, is accompanied by nausea and vomiting, and is severe enough to making walking difficult, acute labyrinthitis or acute vestibular neuronitis are likely causes, Dr. Kay said. He added that these conditions are the result of a viral infection. In some — but not all — cases, the person may have recently had or still be experiencing a cold, flu-like symptoms or some other obvious illness that now is affecting the inner ear.

“In rare instances, these symptoms can indicate a stroke, although in such cases the patient usually is experiencing other neurological symptoms, as well, such as weakness on one side, a drooping face, or difficulty speaking,” Dr. Kay said, stressing that people should seek immediate medical attention if they have symptoms of stroke.

The vertigo induced by Meniere’s disease typically lasts longer than that caused by BPPV but, in most cases, not as long as the spinning brought on by acute labyrinthitis or acute vestibular neuronitis.

“With Meniere’s, the vertigo can last for a few hours, and generally is accompanied by hearing loss, tinnitus — or ‘ringing in the ear’ — and a sense of fullness in one ear,” Dr. Kay said before adding that Meniere’s is a chronic condition with episodes that can be triggered by a variety of factors, such as eating a meal rich in salt, sugar, or the flavor enhancer monosodium glutamate (MSG).

Beyond taking a thorough history to explore the duration of vertigo and potential precipitating factors, Dr. Kay also performs a physical examination on each patient and often does a hearing test in his office. While those steps are sufficient to make a diagnosis and select a treatment plan for most patients, Dr. Kay also is able to perform another in-office test when further information is needed. This test is called videonystagmography, or (VNG). In this evaluation, the patient puts on a pair of goggles and follows the movement of a bouncing ball that appears on the goggles’ screen. The test tracks a type of involuntary eye movement, called nystagmus, that can provide important clues to the cause of the person’s vertigo. This also includes caloric stimulation, which involves gently introducing a small amount of cold air, and then warm air, into each ear, while monitoring the eyes for signs of nystagmus. The test is used to identify potential damage to the acoustic nerve, which helps control hearing and balance. Test results also can reveal potential brain stem issues, which are uncommon causes of vertigo.

Tailoring the Treatment to the Cause

With the cause of vertigo identified, Dr. Kay is able to prescribe treatments that will be effective for the overwhelming majority of patients.

“Acute labyrinthitis and acute vestibular neuronitis typically resolve on their own over time. However, the impact of those conditions can be significant, particularly early on in their course, and steroids work well to reduce the underlying inflammation,” Dr. Kay said.

He also will use the antihistamine meclizine, which affects the central nervous system and is available in over-the-counter formulations including Antivert, Bonine and Dramamine Less Drowsy Formula. Diazepam, known by the brand name Valium, also can work well in certain cases, the ENT noted.

Steroids and diuretics also can play a role in the management of Meniere’s disease, and in this case can be given either orally or through injection directly into the ear, Dr. Kay said.

Meanwhile, more than 90% of people experiencing BPPV can obtain relief from learning and regularly practicing simple physical maneuvers that help reposition the tiny crystals that have found their way into the inner ear’s semi-circular canals, according to Dr. Kay. He said that a number of medications have proven effective in treating vestibular migraine, but that a period of trial and error often is needed to determine which medication works best for a given patient.

The Bottom Line

“Vertigo is a very treatable condition,” Dr. Kay said. However, because of the subjective nature of vertigo, it can be difficult for patients to accurately describe what they are experiencing and, as a result, for non-specialist physicians to correctly identify the underlying cause and thus choose the most appropriate treatment.

“Most cases of vertigo arise from conditions affecting the ear, its tissues and its nerves. For that reason, I urge people experiencing vertigo to be evaluated by an ear, nose and throat specialist, because the training we receive as ENTs and the high volume of vertigo cases we manage make us uniquely suited to assess and treat the condition.

“I have had two bouts of labyrinthitis over the course of my life, so I know how miserable vertigo can be. What I want others who are experiencing vertigo to know is that help is at hand, and that with the right diagnosis, we are able to select a therapy that will stop the spinning for the great majority of people.”

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Dr. Kay received his undergraduate and medical degrees from the University of Pennsylvania. He then completed two years of general surgery residency at Einstein Medical Center in Philadelphia and Mount Sinai Medical Center, and a residency in otolaryngology/head and neck surgery at Columbia Presbyterian Medical Center in New York City. This was followed by a year-long fellowship in facial plastic and reconstructive surgery at Shadyside Hospital in Pittsburgh, where he also received training in endoscopic sinus surgery. Dr. Kay founded Princeton Otolaryngology Associates in 1993, and for almost 30 years has offered the full range of ENT services, providing expert care to thousands of people from Middlesex and Mercer counties and surrounding communities.

For more information about the evaluation and treatment of vertigo and the other services provided by Princeton Otolaryngology Associates, or to make an appointment to see Dr. Kay at the practice’s Monroe or Plainsboro offices, call 609-445-4445 or visit www.drscottkay.com.